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Objective: Assess the primary causes and preventability of maternal near misses (MNM) and mortalities (MM) at the largest tertiary referral hospital in Rwanda, Kigali University Teaching Hospital (CHUK)., Methods: We reviewed records for all women admitted to CHUK with pregnancy-related complications between January 1st, 2015 and December 31st, 2015. All maternal deaths and near misses, based on WHO near miss criteria were reviewed (Appendix A). A committee of physicians actively involved in the care of pregnant women in the obstetric-gynecology department reviewed all maternal near misses/ pregnancy-related deaths to determine the preventability of these outcomes. Preventability was assessed using the Three Delays Model.[1] Descriptive statistics were used to show qualitative and quantitative outcomes of the maternal near miss and mortality., Results: We identified 121 maternal near miss (MNM) and maternal deaths. The most common causes of maternal near miss and maternal death were sepsis/severe systemic infection (33.9%), postpartum hemorrhage (28.1%), and complications from eclampsia (18.2%)/severe preeclampsia (5.8%)/. In our obstetric population, MNM and deaths occurred in 87.6% and 12.4% respectively. Facility level delays (diagnostic and therapeutic) through human error or mismanagement (provider issues) were the most common preventable factors accounting for 65.3% of preventable maternal near miss and 10.7% maternal deaths, respectively. Lack of supplies, blood, medicines, ICU space, and equipment (system issues) were responsible for 5.8% of preventable maternal near misses and 2.5% of preventable maternal deaths. Delays in seeking care contributed to 22.3% of cases and delays in arrival from home to care facilities resulted in 9.1% of near misses and mortalities. Cesarean delivery was the most common procedure associated with sepsis/death in our population. Previous cesarean delivery (24%) and obstructed/prolonged labor (13.2%) contributed to maternal near miss and mortalities., Conclusion: The most common preventable causes of MNM and deaths were medical errors, shortage of medical supplies, and lack of patient education/understanding of obstetric emergencies. Reduction in medical errors, improved supply/equipment availability and patient education in early recognition of pregnancy-related danger signs will reduce the majority of delays associated with MNM and mortality in our population., Competing Interests: The authors have declared that no competing interests exist.

Background: To determine the prevalence and factors associated with severe ('near miss') maternal morbidity and mortality in the University Teaching Hospital of Kigali-Rwanda., Methods: We performed a cross sectional study of all women admitted to the tertiary care University Hospital in Kigali with severe "near miss" maternal morbidity and mortality during a one year period using the WHO criteria for 'near miss' maternal mortality. We assessed maternal demographic characteristics and disease processes associated with severe obstetric morbidity and mortality., Results: The prevalence of severe maternal outcomes was 11 per 1000 live births. The maternal near miss ratio was 8 per 1000 live births. The majority of severe obstetric morbidity and mortalities resulted from: sepsis/peritonitis (30.2%)--primarily following caesarean deliveries, hypertensive disease (28.6%), and hemorrhage (19.3%). Majority of our patients were found to be of lower socioeconomic status, refered from district hospitals to the tertiary care center, and resided in the eastern part of the country., Conclusion: The main causes associated with MNH were peritonitis, hypertensive disorders and bleeding. The high prevalence of peritonitis may reflect suboptimal intraoperative and intrapartum management of high-risk patients at district hospitals. Direct causes of severe maternal outcome are still the most prevalent. The study identified opportunities for improvement in clinical care to reduce potentially these adverse outcomes.

The maternal-fetal medicine subspecialist plays a critical role in the evaluation and management of women with obstetrical and medical comorbidities. These women have a higher risk for obstetrical morbidity, "near miss," and maternal mortality. Maternal death surveillance is essential to understand the factors that contribute to maternal mortality. Maternal-fetal medicine subspecialists' involvement and leadership in peer review of maternal deaths can provide guidance in developing and supporting management protocols to the obstetrical community and health care facilities., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: To determine the impact of ethnicity on "near miss"/severe obstetric morbidity in a multi-ethnic, tertiary care population., Methods: We carried out a cross-sectional analysis using birth data for 12,774 women with Medicaid who gave birth between January 1994 and January 2005 at Duke University. Univariate and multivariate analyses were carried out to compare ethnic groups and risk factors for severe obstetric morbidity and mortality using codes for conditions corresponding to the WHO definitions of near miss maternal morbidities., Results: African-American women experienced significantly more pregnancy complications (25.4%) compared to White (21.7%) and Hispanic (18.8%) women. The presence of medical comorbidities was highest among African-Americans (9.1%) compared to Whites (8.1%) and Hispanics (2.6%). Near miss mortality, however, was significantly higher in Hispanic women (5.9%) compared to African-Americans (4.6%), and Whites (4.1%). Hispanic women had 45% greater risk of near miss mortality compared to Whites (relative risk [RR] = 1.45, 95% confidence interval [CI]: 1.14-1.84) whereas differences were non-significant for African-American women. In multivariate regression, near misses remained highest for Hispanic women (RR = 1.66; 95% CI: 1.27-2.17)., Conclusions: The increase in near miss maternal mortality for Hispanic women suggests a more complex interaction between ethnicity, socioeconomic status and health than traditional birth outcome measures capture., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective  We sought to characterize the incidence and risk factors associated with developing maternal morbidity following preterm prelabor rupture of membranes. Study Design  Retrospective case–control study of patients with preterm prelabor rupture of membranes at a single institution from 2013 to 2019 admitted at ≥23 weeks gestational age. The primary outcome was a composite of maternal morbidity which included: death, sepsis, intensive care unit (ICU) admission, acute kidney injury, postpartum dilation and curettage, postpartum hysterectomy, venous thromboembolism, postpartum hemorrhage, postpartum wound complication, postpartum endometritis, pelvic abscess, postpartum pneumonia, readmission, and/or need for blood transfusion were compared with patients without above morbidities. Severe morbidity was defined as: death, ICU admission, venous thromboembolism, acute kidney injury, postpartum hysterectomy, sepsis, and/or transfusion >2 units. Demographics, antenatal, and delivery characteristics were compared between patients with and without maternal morbidity. Bivariate statistics and regression models were used to compare outcomes and calculate adjusted odd ratios. Results  Of 361 included patients, 64 patients (17.7%) experienced maternal morbidity and nine (2.5%) had severe morbidity. Patients who experienced maternal morbidity were significantly (p  < 0.05) more likely to be older, have private insurance, have BMI ≥40, have chorioamnionitis at delivery, and undergo cesarean or operative vaginal delivery when compared with patients who did not experience morbidity. After controlling for confounders, cesarean delivery (aOR 2.38, 95% CI[1.30,4.39]), body mass index ≥40 at admission (aOR 2.54, 95% CI[1.12,5.79]), private insurance (aOR 3.08, 95% CI[1.54,6.16]), and tobacco use (aOR 3.43, 95% CI[1.58,7.48]) were associated with increased odds of maternal morbidity. Conclusion  In this cohort, maternal morbidity occurred in 17.7% of patients with preterm prelabor rupture of membranes. Private insurance, body mass index ≥40, tobacco use, and cesarean delivery were associated with higher odds of morbidity. These data can be used in counseling and to advocate for smoking cessation. Key Points 17.7% of patients with PPROM experienced maternal morbidity. BMI ≥40 was associated with higher odds of maternal morbidity. Tobacco use and cesarean delivery were associated with higher odds of maternal morbidity. [ABSTRACT FROM AUTHOR]

The disparity in maternal mortality for African American women remains one of the greatest public health inequities in the United States (US). To better understand approaches toward amelioration of these differences, we examine settings with similar disparities in maternal mortality and “near misses” based on race/ethnicity. This global analysis of disparities in maternal mortality/morbidity will focus on middle- and high-income countries (based on World Bank definitions) with multiethnic populations. Many countries with similar histories of slavery and forced migration demonstrate disparities in health outcomes based on social determinants such as race/ethnicity. We highlight comparisons in the Americas between the US and Brazil—two countries with the largest populations of African descent brought to the Americas primarily through the transatlantic slave trade. We also address the need to capture race/ethnicity/country of origin in a meaningful way in order to facilitate transnational comparisons and potential translatable solutions. Race, class, and gender-based inequities are pervasive, global themes. This approach is human rights—based and consistent with the UN Millennium Development Goals (MDG) and post 2015—sustainable development goals’ aim to place women’s health the context of health equity/women’s rights. Solutions to these issues of inequity in maternal mortality are nation-specific and global. [ABSTRACT FROM AUTHOR]

Background: The objective of this study is to evaluate 'near miss' and mortality in women with postpartum infections.Methods: We performed a retrospective review of all patients referred to the University Teaching Hospital of Kigali (CHUK) between January 2012 and December 2013. We identified 117 patients with postpartum infections. Demographic data, length of admission, location of referral, initial surgery and subsequent treatment modalities including antibiotic administration and secondary surgery were recorded. The primary outcome of interest was a composite of maternal mortality and "near miss" defined as more than one laparotomy with/without hysterectomy and prolonged hospitalization.Results: Diagnoses at CHUK were: pelvic peritonitis (56 %), deep surgical site infection including fasciitis (17 %), and endometritis (15 %). The primary procedures performed prior to transfer were: cesarean section (81 %), septic abortion management (12 %), and vaginal delivery (7 %). Antibiotics were initiated prior to transfer in 66 % of women. Surgery was required in 73 % of patients. Hysterectomies were performed in 22 % of patients. Maternal death occurred in 5 % of the patient population. The primary outcome of severe maternal morbidity and mortality occurred in 90 patients (77 %).Conclusion: Peritonitis-primarily as a result of cesarean deliveries-is associated with significant morbidity and mortality in our population. [ABSTRACT FROM AUTHOR]

Hypertension is a major global public health risk and significant precursor to cardiovascular disease, stroke, diabetes and maternal mortality. A possible strategy to reduce chronic disease in resource-poor areas is social intervention. Research into the possible relationship of social determinants and disease is needed to determine appropriate social interventions. This study aims to determine the association between social capital and hypertension in rural Haitian women. From June to August 2005, 306 women, ages 18-49, who attended one of Hôpital Albert Schweitzer's five rural dispensaries as patients or accompanying patients, were interviewed. Individual interviews on social capital, demographics and anthropometrics were conducted. SAS statistical package was used to analyze the data. Groups/networks, personal empowerment, collective action/cooperation and trust components significantly decreased the likelihood of hypertension in multivariate analysis. In an additive model, the ranked index of social capital indicated that each social capital component score above the conceptual midpoint showed a 41 % reduction in the likelihood of hypertension. The findings suggest that interventions aimed to increase components of social capital may significantly lower hypertension. [ABSTRACT FROM AUTHOR]

Objective . The maternal mortality ratio in Haiti remains one of the highest in the world at 600/100 000 live births. Preeclampsia- and eclampsia-related complications are one of the leading causes of maternal death. In this resource-limited setting, effective, efficient hospital-based interventions are necessary to reduce this risk. Our objective was to assess the utility of common laboratory and clinical admission data for the determination of preeclampsia- and eclampsia-related maternal death. Study design . We performed an analysis of women presenting to the Hôpital Albert Schweitzer with preeclampsia and eclampsia during a 3-year period. Factors analyzed were: maternal age, parity, gestational age, hematocrit, serum creatinine, urine protein, systolic and diastolic blood pressure, intrauterine fetal death (IUFD), coma on arrival, and address (residence within or outside hospital catchment area). Stepwise logistic regression identified factors predictive of maternal mortality. Results . Preeclampsia/eclampsia affected 423 of 2295 deliveries (18%) and resulted in 19 deaths. Multivariate analysis identified the following predictors of maternal mortality: IUFD (RR 7.57; 95% CI 2.76–12.69), eclampsia (RR 6.91; 95% CI 2.08–12.64), and oliguria (RR 5.39; 95% CI 1.80–10.69). Conclusion . In this setting, traditional admission laboratory and clinical tests were not useful in maternal mortality prediction. The analysis highlights clinical characteristics of women at highest risk for maternal death. [ABSTRACT FROM AUTHOR]

This 2009 qualitative study investigated Haitian women's most pressing health needs, barriers to meeting those needs and proposed solutions, and how they thought the community and outside organizations should be involved in addressing their needs. The impetus for the study was to get community input into the development of a Family Health Centre in Leogane, Haiti. Individual interviews and focus group discussions were conducted with 52 adult women in six communities surrounding Leogane. The most pressing health needs named by the women were accessible, available and affordable health care, potable water, enough food to eat, improved economy, employment, sanitation and education, including health education. Institutional corruption, lack of infrastructure and social organization, the cost of health care, distance from services and lack of transport as barriers to care were also important themes. The involvement of foreign organizations and local community groups, including grassroots women's groups who would work in the best interests of other women, were identified as the most effective solutions. Organizations seeking to improve women's health care in Haiti should develop services and interventions that prioritize community partnership and leadership, foster partnerships with government, and focus on public health needs. Cette étude qualitative de 2009 a enquêté sur les besoins de santé les plus pressants des Haïtiennes, les obstacles empêchant de les satisfaire et les solutions proposées, et comment la communauté et les organisations extérieures devaient à leur avis s'impliquer pour répondre à leurs besoins. La dynamique de l'étude était d'inclure les contributions communautaires dans la création d'un centre de santé familiale à Léogâne, Haïti. Des entretiens individuels et des discussions de groupe ont été menés avec 52 femmes adultes dans six communautés proches de Léogâne. Les besoins de santé les plus pressants cités par les femmes étaient des soins de santé accessibles, disponibles et d'un coût abordable, l'eau potable, suffisamment à manger, l'amélioration de la situation économique, des emplois, l'assainissement et l'éducation, y compris l'éducation sanitaire. La corruption institutionnelle, le manque d'infrastructures et d'organisation sociale, le coût des soins, la distance des services et l'absence de transport comme obstacles aux soins étaient aussi des points importants. La participation d'organisations étrangères et de groupes communautaires locaux, notamment des groupes de femmes qui agiraient dans les meilleurs intérêts d'autres femmes, a été identifiée comme la solution la plus efficace. Les organisations souhaitant améliorer les soins de santé des femmes en Haïti devraient créer des services et des interventions qui donnent la priorité au leadership et aux partenariats communautaires, favorisent la collaboration avec les autorités et se centrent sur les besoins de santé publique. En este estudio cualitativo realizado en 2009 se investigaron las necesidades de salud más apremiantes de las mujeres haitianas, las barreras para satisfacer esas necesidades, las soluciones propuestas y las opiniones de las mujeres en cuanto al rol de la comunidad y organizaciones externas para atender sus necesidades. El ímpetu del estudio fue obtener las ideas y opiniones de la comunidad respecto a la creación de un Centro de Salud de la Familia en Leogane, Haití. Se realizaron entrevistas individuales y discusiones en grupos focales con 52 mujeres adultas en seis comunidades alrededor de Leogane. Las necesidades de salud más apremiantes mencionadas por las mujeres fueron: servicios de salud accesibles y disponibles a precios asequibles, agua potable, suficientes alimentos para comer, mejor economía, empleo, servicios sanitarios y educación, incluida la educación sobre la salud. Además, mencionaron como barreras a los servicios de salud la corrupción institucional, la falta de infraestructura y organización social, el costo de los servicios de salud, la distancia a los servicios y la falta de transporte. Como las soluciones más eficaces se identificaron la participación de organizaciones extranjeras y grupos comunitarios, tales como grupos de mujeres de las bases, que trabajarían en beneficio de otras mujeres. Las organizaciones que buscan mejorar los servicios de salud para las mujeres de Haití deberían crear servicios e intervenciones que den prioridad al liderazgo y las alianzas comunitarios, fomentar alianzas con el gobierno y centrarse en las necesidades de salud pública. [ABSTRACT FROM AUTHOR]